HomeMy Public PortalAbout9632 1/2 LONGDEN AVE_Sewer__ 76A642D F.
CE8081.REV.6/78) APPLICATION FOR ERM IT
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SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
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61,
CONNECTION DATA
LOCALITY tzAZ,
NEAREST STATION s - STATION DEPTH
CROSS ST. °�'�
UPPER
-. /r MANHOLE REFERENCE LOWER
OWNER by
�} TYPE OF CONNECTION LENGTH FROM
MAILADDRESS )' ((„ /�-� Y. CURB P.L. M.L.TO P.L.
ii P.C.NO.
CITY I � ' `i' TEL.NO. 9 ,7 s CO.IMP.NO. JOB NO.
LEGAL ^',7 TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO.
AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
BLOCK TRACT,.-.L„�"�,� .iy, -a1'� .d
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING
USE OF L �J
BUILDINGS STATE ENCROACHMENT
PERMIT NO.
''�f Y INDUSTRIAL
CONTRACTOR
WASTE APPROVAL
ADDRESS CHARGES
CITY TEL.NO. CONNECTION CHARGE FEE
STATE -. LIC. " - REIMBURSEMENT FEE d
LICENSE NO. ! - CLASS
NO. DESCRIPTION OF WORK FEEO
APPROVALS DATE INSPECTOR'S SIGNATURE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER 0
NEW HOUSE SEWER
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL d' •^ 7 r
HOUSE SEWER CONNECTING TO BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM a
CONNECT ADDITIONAL BLDG.6R SEPTIC TANK,SEEP,PIT(S)
-WASAWL-4-6 HOUSE SEWER AND/OR DRAINFIELD
OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL ❑ DRYWELL
EXTN..CESSPOOL,DRYWELL,MANHOLE
ALTER,REPAIR OR ABANDON HOUSE ALTER,REPAIR,SEWER OR
SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BAC KFILL SEPTIC TANKS
OWNERS Permit 5 SEEP,PIT(S) CESSPOOLS
AUTHORIZATION FTOTAL FEE I /` VALIDATION
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19—
OWNER OR
OWNERS AGENT
ADDRESS
IHEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS.
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STAY OF
CALIFORNIA OR THAT I AMLEGA pWNER OF,A IN kD T RE-
SIDE IN,THE ABOVE D RI ID ENTIAL PR e'
SIGNATURE ;Y
OF PERMITTEE - " `-
'&A 6420 - CE808 - 9/73 APPLICATION 61h PERM
COUNTY OF LOS ANGELES SEWE -SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS 4 4�t '/cw
LOCALITY -/
S
NEARET le,
OR APPLICANT TO FILL IN CROSS ST. t
LEGAL I -
DESC RIPTION L07 NO. :11� OWNEF Ac t7
MAIL
BLOCK NA -FA i ADDRESS
NO. OF BLOGS. .7> f/
SIZE OF LOT T TEL. NO.
eC.' NOW ON LO CITY
USE OF
BUILDINGS DISTRICT N0.1 0 R!UP BK AP PS el CESSED BY
CONTRACTOR
ADDRESS 4NO CONNECTION DATA
CITY TEL. NO. STATION DEPTH
UPPERSTA E LIC LOWERI MANHOLE REFERENCE.
LICENSE NO, GLASS
No. I DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER 0 $7.00 P.C.NO.
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ 5I0'00 CO.IMP.NO. JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT ADDITIONAL BLDG.ORRECORD.INSTR.NO. DATE
W
_HOUSE SEWER $3.00
OVERFLOW SEEPAGE-P�l .-0R`Ai-NFfELO
EXTN..CESSPOOL.DRYWELL, $-,.Do
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM $3,00
STATE ENCROACHMENT
C-7
PERMIT NO.
MANHOLE 0 $7.00 LJ
INDUSTRIAL CL.
WASTE APPROVAL
CHARGES
OWNER'S PERMIT $
AUTHORIZATION I TOTAL FEE CONNECTION CHARGE PEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC
Sr APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF ze�t 19
OWNER OR
NEW HOUSE SEWER
OWNEkR
S AGENTCONNECT ADDITIONAL
ADDRESS—
BUILDING OR WORK
SEPTIC TANK.SEEP,PIT(S)
I HEREBYACkN6WL�C)Gi THAT I 4AVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE
THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL 0 DRYWELL [j
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED
AS REOUtRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CAL I FCRN I A OR THAT I AM THE LE G AL OWNER OF, AND INTEND TO DISCONNECT PLUG AN
RESIDE IN. THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY, ABANDON HOUSE SEWER
SIGNATURE
OF PE4RMtTTEE-, BACKFILL SEPTIC TANKS
SEEP.PIT(S) ❑ CESSPOOLS O�
— ❑
--
VALIDATION M.0. CASH
9
A�L 3 0
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